Eitanim Young Mentors 2022-2023Please enable JavaScript in your browser to complete this form.Parent InformationName *FirstLastEmail *Phone *Home Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRegistrationHow many kids would you like to register? *123Participant InformationName *FirstLastEmail *Phone *Birth Date *Gender *FemaleMaleOtherIdentity *IsraeliIsraeli-AmericanJewish-AmericanOtherGrade Entering in 2022-2023 *10th Grade11th Grade12th GradeName of SchoolHow did you hear about us?What do you know about Young mentors? *If we were to ask your friends or family about you, what would they say? *What is a talent you are proud of? Or what is a project you have done and are proud of? *Tell us about yourself (school/family/hobbies/etc.) *Why do you want to take part in the program? Was it your idea or did your parents make you join? *Have you participated in a leadership/mentorship program before? *YesNoHave you worked in a group or team setting remote before? How did you feel about it? *Please indicate two things that you would like to have or improve in your school: *If you could create any app or software that would solve a problem, what would you solve? how? *Are you willing and able to commit to attend all Young mentors sessions? *Absence from more than one session could result in your elimination from the program? *YesNoInstagram username:2nd Participant InformationName *FirstLastEmail *Phone *Birth Date *Gender *FemaleMaleOtherIdentity *IsraeliIsraeli-AmericanJewish-AmericanOtherGrade Entering in 2022-2023 *10th Grade11th Grade12th GradeName of SchoolHow did you hear about us?What do you know about Young mentors? *If we were to ask your friends or family about you, what would they say? *What is a talent you are proud of? Or what is a project you have done and are proud of? *Tell us about yourself (school/family/hobbies/etc.) *Why do you want to take part in the program? Was it your idea or did your parents make you join? *Have you participated in a leadership/mentorship program before? *YesNoHave you worked in a group or team setting remote before? How did you feel about it? *Please indicate two things that you would like to have or improve in your school: *If you could create any app or software that would solve a problem, what would you solve? how? *Are you willing and able to commit to attend all Young mentors sessions? *Absence from more than one session could result in your elimination from the program? *YesNoInstagram username:3rd Participant InformationName *FirstLastEmail *Phone *Birth Date *Gender *FemaleMaleOtherIdentity *IsraeliIsraeli-AmericanJewish-AmericanOtherGrade Entering in 2022-2023 *10th Grade11th Grade12th GradeName of SchoolHow did you hear about us?What do you know about Young mentors? *If we were to ask your friends or family about you, what would they say? *What is a talent you are proud of? Or what is a project you have done and are proud of? *Tell us about yourself (school/family/hobbies/etc.) *Why do you want to take part in the program? Was it your idea or did your parents make you join? *Have you participated in a leadership/mentorship program before? *YesNoHave you worked in a group or team setting remote before? How did you feel about it? *Please indicate two things that you would like to have or improve in your school: *If you could create any app or software that would solve a problem, what would you solve? how? *Are you willing and able to commit to attend all Young mentors sessions? *Absence from more than one session could result in your elimination from the program? *YesNoInstagram username:Parent/Guardian #1 Name *FirstLastPhone Number *Email *Parent/Guardian #2 Name *FirstLastPhone Number *Email *Medical Information & Release In case of injury or illness of a child while at IAC Young mentors, every effort will be made to contact a parent or guardian. If you cannot be reached, we will call the emergency contacts you listed, or your child's doctor - or an ambulance, if necessary.Terms and Conditions For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby authorize Israeli-American Council (IAC) permission to use my likeness in a photographic image(s) (photographs in any format, still, single, multiple, moving or video) in any and all of its publications, including but not limited to all Israeli-American Council (IAC), printed and digital publications and communications. I understand and agree that any photographic image(s) using my likeness will become property of Israeli-American Council (IAC) and will not be returned.I acknowledge that since my participation with Israeli-American Council (IAC) is voluntary, I will receive no financial compensation.I hereby irrevocably authorize Israeli-American Council (IAC) to edit, alter, copy, exhibit, publish or distribute this photo(s) for purposes of publicizing Israeli-American Council (IAC) programs and events or for any other related, lawful purpose.I understand that I will be responsible for any and all payments subsequent as well as any and all follow ups that medical staff deem necessary.In addition, I waive the right to inspect or approve the finished product including written or electronic copy, wherein my likeness appears.Additionally, I waive any rights to royalties or other compensation arising or related to the use of the photograph(s).I hereby release the IAC, its contractors, clients, employees, officers, legal heirs, investors, agents, representatives, and assigns from all liability for any claims by me, my minor child, my family, my heirs, legal representatives and assigns or any third party in connection with my or my child’s participation, including any claims and demands ensuing from or in connection with the use of the photographic image(s), including any and all claims for libel and invasion of privacy.I also release them from any expectation of confidentiality for the use of said photographs. IAC Eitanim is a safe, caring community where individual differences are valued, where people are supported in reaching their goals and accomplishing challenges, and where everyone can have fun, work and learn. Because creating such a community requires the commitment of all participants, we ask everyone to agree to the behavior expectations. Continued inappropriate behavior or severely inappropriate behavior (such as physical or emotional violence, bullying, or possession of prohibited items) will result in immediate dismissal from our program and forfeiture of program fees. The parent/guardian is responsible for removing a dismissed student immediately. We ask both the student and the parent/guardian to sign the Behavior Agreement section down below to confirm that you have read this document together and acknowledge and accept the responsibility to meet these behavior expectations. In consideration of the IAC allowing me and/or my minor child(ren) or ward(s) to attend and/or participate in any programs, events, classes, or other activities at the IAC and/or sponsored by the IAC, I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the IAC and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all rights and claims for any loss, damage, illness or injuries to person or property sustained as a result of my attendance and/or participation in any such programs, events, classes, and other activities, whether or not such loss, damage or injury results from the negligence of the IAC and its employees, agents, or representatives or from some other cause. My agreement to release the IAC does not include any loss, damage or injury that results from the IAC's gross negligence or willful, wanton, or reckless misconduct. I further waive any and all rights to inspect or approve the photograph, videotape, television program, motion picture, tape recording or other use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es), including any written article, script, caption or other writing that may accompany such use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es). I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the IAC and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all liability, claims, losses, costs, expenses or damages for libel, slander, invasion of privacy, conversion, defamation, appropriation of likeness or any other claim based on the use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) in any such materials. I hereby represent and warrant to the IAC that I have the authority to execute this Participant Waiver Form on behalf of myself and/or on behalf of my minor child(ren) or ward(s) as parent, guardian and/or next friend, if applicable. In the event of any misrepresentation or breach of the foregoing warranty by me, or in the event that I, my minor child(ren) or ward(s), or any other person nevertheless asserts any claim against the IAC arising out of my or my minor child(ren)’s or ward(s)’ participation in any program, event, class or other activity as set forth herein. I agree to indemnify, hold harmless and defend the IAC from and against any and all liability, claims, losses, costs, expenses or damages resulting therefrom, including, but not limited to, claims of loss, damage, illness or injury to person or property whether or not such loss, damage, illness or injury results from the negligence of the IAC or from some other cause. I expressly acknowledge and agree to the terms and conditions set forth on this Participant Waiver Form.Checking the I ACCEPT box is indicating your authorization and is legally equivalent to your actually signing this document. * I ACCEPT1 Young mentorsPrice: $ 200.002 Young mentorsPrice: $ 380.003 Young mentorsPrice: $ 560.00Total$ 0.00Stripe Credit Card *CardName on CardSubmit
